A female patient of age 45 years came to the medical opd with chief complaints of pain from waist to knee and was unable to swallow food or drink water.

Hi, I am Ananya Aleti  a 5th Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

Date of admission- 01-06-2023

 A 45 year old female patient   came to the medical opd with chief complaints of pain from waist to knee and was unable to swallow food or drink water.

 History of presenting illness:- patient was apparently asymptomatic 3 months ago and then she fell down in the bathroom backwards. She was fine for 5 days and then she was unable to walk or get up from supine position.

I month ago she developed dysphagia where she couldn’t drink or eat something.

She had pain while swallowing. And she stopped eating since 10 days ago and it was associated with several episodes of vomiting after eating

She also had severe pain which was radiating from hip to knee of both lower limbs. The was sudden in onset, gradually increased , twisting type of pain, no relieving or aggravating factors. Associated with weight loss of about 20 kgs.

No h/o epigastric pain

Fever

Burning micturition

Heart burn

Bleeding sites 

Hemoptysis 

Diarrhoea or bloating

On palpation 

No mass per abdomen

Or tenderness found.

History of past illness :-

12 years ago the patient went to a hospital for leg pain and has found with decrease in function of a kidney as there was anuria the attendants are unsure of which. She has taken medication for it.

Past history:

No h/o DM

HTN

Epilepsy, thyroid

TB,

Asthma,

Had blood transfusion during delivery 

Surgical history: 

LSCS-1

 Family history 

No significant history 

Personal history

Married 

Mixed diet

Normal bowel movements 

But low urine output

No burning micturition

Loss of appetite 

No known addictions or allergies

General examination 

Conscious, coherent 

 Presence of pallor

No cyanosis 

No icterus 

No clubbing of fingers

No lymphadenopathy 

No pedal Edema

Vitals

BP 90/60 mmhg

PR - 90 beats/ min

Spo2- 99%

Temp: 98.2F

GRBS - 109 mg/dl ( present)

Investigations:

GRBS - 82 mg/dl

Blood urea- 135 mg/dl

Serum creatinine- 4mg/ dl

 Electrolytes

Sodium - 143 m Eq/ l

Potassium- 4 mEq/l

Chlorine - 108 mEq/l

T. Bilirubin - 1.5 mg/dl

D. Bilirubin- 0.27 mg/ dl

 

SGPT- 10 IU/L

SGOT - 10 IU/L

ALP - 345 IU/L

T proteins - 4.6g/dl

Albumin - 2.03 g/dl

A/G ratio - 0.7

RADIOLOGICAL INVESTIGATIONS 

 

Systemic Examination 

CNS examination 

1 . Level of consciousness-  conscious

2. Speech - normal

3. Signs of meningeal irritation- 

         - no neck stiffness 

          - no Kernig’s sign

 4. Cranial nerves - normal

5. Motor system - normal

6. Sensory system - normal

CVS examination 

No thrills

Cardiac sounds - S1 and S2 present

Cardiac murmurs - absent

Respiratory examination 

No dyspnea 

No wheezing 

Position of trachea- central

Breath sounds - vesicular 

Abdomen 

 Shape of abdomen - scaphoid

Tenderness - absent

Palpable mass - absent 

Hernial orifices - normal

Free fluid-  absent

Spleen - not palpable

Liver - not palpable 

Bowel sounds - yes

Treatment

3-06-23

1. Optineuron - 1 amp i.v OD

4-06-23

 Optineuron - 1 amp i.v OD

T. MVT

Lactulose TD

Shelcal tab- OD

6-06-23

T.Naredrena 2amp

T.Nitrofurantoin 100mg oral TID

IV NS @ 75ml/hr

Syp lactulose 15ml oral TID